300 Campus Drive Bradford, Pennsylvania 16701

Phone: 814-362-7548, 814-362-7566 Fax: 814-362-7607 www.upb.pitt.edu

The goals of TRIO Student Support Services are to support students in reaching their academic goals. The program provides opportunities that will enrich their university experience and help students gain

the skills needed to be competitive in the future job market.

Date Received: ___________________________ Received By: _____________________________

Entered Into Student Access By______________ Date Entered Into SA ______________________ Student Emplid # _________________________

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TRIO Student Support Services Application

Please print clearly and complete all questions The TRIO Student Support Services program is a federally funded program and collects demographic information

for statistical purposes only. TRIO SSS is committed to serving all persons seeking services, and we encourage

applications from students of diverse backgrounds. In accordance with the University of Pittsburgh’s

nondiscrimination policy, no distinction is made upon the basis of race, color, religion, national origin, ancestry, sex,

age, marital status, sexual orientation, gender identity and expression, genetic, information, disability, or status as a

veteran. For the full policy statement, go to hr.pitt.edu/diversity. Demographic data will not be used for

determining your eligibility to participate in the TRIO Student Support Services program.

Last Name: ___________________________First Name: _________________________M.I___________

Maiden Name: __________________________________ Date of Birth: ________________________

Gender ☐Male ☐Female (Check One)

Local/Campus Address: Permanent Address

Street: _________________________________ Street: ________________________________

City: ___________________________________ City: __________________________________

State, Zip: ______________________________ State, Zip ______________________________

Phone: ________________________________ Phone: ________________________________

Cell Phone: _____________________________ Cell Phone _____________________________

Pitt Email: _____________________________ Personal Email:________________________

Are you of Hispanic, Latino or Spanish origin? Yes No

If yes, you MUST also identify a “Race” Below

Race/Ethnicity (mark any that apply): ☐American Indian or Alaskan Native

☐Asian

☐Black or African-American

☐Caucasian or White

☐Native Hawaiian or other Pacific Islander

English is My Second Language: ☐Yes ☐No

If yes, what is your first language? _______________________________________________

Are you a U.S. Citizen? ☐ Yes ☐No

If no, are you a Permanent Resident? ☐Yes ☐ No

Are you a Veteran? ☐Yes ☐No

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TRIO SSS Eligibility Requirements To be eligible for TRIO SSS, students must meet one or more of the following:

Be a first-generation college student (neither parent or guardian has completed a four-year college degree)

Meet federal low-income guidelines

Have a documented disability

Also, every applicant must be:

Enrolled at University Pittsburgh at Bradford

Enrolled in a 4-year program (Bachelor’s Degree)—Associate Degree programs not eligible

A U. S Citizen or national of the United States or meets the residency requirements for Federal Student

Financial Aid

In need of academic support, as determined by UPB, in order to purse successfully a postsecondary

educational program

Consent to exchange or request Information to determine TRIO SSS eligibility

I, _______________________________________, give my consent to TRIO Student Support Services (SSS)

program staff members to obtain information from the following UPB offices for determination of program

eligibility and federal reporting.

(a) Financial Aid

(b) Disability Resources and Services

(c) Admissions/Enrollment Management/Registrar/Academic Affairs / Student Affairs

(d) Athletics/Communications & Marketing

First Generation Eligibility

Does either parent (biological or adoptive) have a baccalaureate (4-year) degree?

(Parent 1 and Parent 2 are required to be answered for eligibility)

Parent 1: ☐Yes ☐No Parent 2: ☐Yes ☐No

Prior to the age of 18, did you regularly reside and receive support from only one parent who did not have a

baccalaureate degree? ☐Yes ☐No

Additional Questions:

At any time since you turned 13, were you an orphan, in foster care, a dependent or ward of the court?

☐Yes ☐No

Has it been decided by a court of your state of legal residence that you are an emancipated minor or that you are in

legal guardianship? ☐Yes ☐No

At any prior to the age of 24, were you determined to be an unaccompanied youth who was homeless as determined

by your high school or district homeless liaison or director of an emergency shelter or transitional housing program

funded by the U.S. Department of Housing and Urban Development? ☐Yes ☐No

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Disability Eligibility

Do you have a documented physical, medical, or psychological disability? ☐Yes ☐No

If yes, have you registered with Pitt-Bradford’s Disability Resource and Services: ☐Yes ☐No

(Registration with DRS is required for admittance to TRIO SSS)

If you have not registered, please contact: Carma Horner

814-362-7609

clh71@pitt.edu

Income Eligibility

(PARENT information is required for “dependent” students – i.e. if the student is less than 24 years old, not

married, not emancipated, parental income is reported on FAFSA )

(PARENT information is NOT required for “independent” students—i.e. if student is 24 or older, married or

emancipated, parental income is not reported on FAFSA)

The student is considered: ☐ Dependent ☐Independent

☐ My Parents/Guardians or I filed a 2017 Tax Return

a. 2017 household taxable income (1040—line 43, 1040EZ—line 6, 1040A—Line 27) ______________

b. How many people in your household were claimed for 2017 tax purposes? _________

☐ My Parents/Guardians or I DID NOT FILE a federal income tax return for 2017

Total Income $_____________________

☐ My Parents/Guardians or I Had no Taxable Income for 2017

SIGNATURES REQUIRED:

Parent/Guardian Signature: By signing below, I certify that all of the information on this form is true and complete

to the best of my knowledge. If requested, I agree to give proof of the information, including a copy of my federal

income tax return. I give the TRIO Student Support Services program permission to verify and receive information

from the University of Pittsburgh at Bradford’s Office of Financial Aid and Office of Admissions.

____________________________________________ __________________

Parent/Guardian Signature (required if student is declared “Dependent)) Date

Student Signature: By signing below, I the student certify that all of the information on this form is true and

complete to the best of my knowledge. If requested, I agree to give proof of the information, including a copy of my

federal income tax return. I give the TRIO Student Support Services program permission to verify and receive

information from the University of Pittsburgh at Bradford’s Office of Financial Aid and Office of Admissions.

____________________________________________ __________________

Student Signature (required in all cases) Date

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Prior Participation in a TRIO Program? ☐No ☐Yes, where? ___________________________

☐Student Support Services ☐Talent Search

☐Upward Bound ☐EEOC

APPLICANT’S ACADEMIC INFORMATION

Previous Education

High school attended: ____________________________________________☐Diploma ☐GED

Year Graduated _________

Did you attend a College in High School, Bridges, or Dual Enrollment Program? ☐Yes ☐No

Are you a transfer student? ☐ Yes ☐No ☐ Copy of transcript is attached to application.

☐ TRIO SSS is to request transcript from UPB

Enrollment Services

Have you received a college degree? ☐Associate (2yr) ☐ Bachelor (4yr)

University of Pittsburgh at Bradford Educational Plans New UPB Student

Enrollment Information: Major(s): __________________________________________________

Minor(s) __________________________________________________

Financial Aid: Is your FAFSA submitted? ☐Yes ☐No

Are you eligible/or do you receive Veteran Benefits? ☐Yes ☐No

Enrollment Status: ☐Full time ☐¾ time ☐Part-time ☐Other

(12+credits) (9-11 credits) (6-8 credits)

Academic Level: ☐New Freshman ☐Sophomore—23.5-53 credits

☐Junior—53.5-83 credits ☐Senior—83.5+ credits

Degree Plans at UPB: ☐Bachelor’s ☐Associate

Future Degree Plans (after UPB): ☐Doctorate ☐Master’s ☐Bachelor’s ☐Unsure ☐None

Will You be Transferring from UPB before Graduating? ☐Yes ☐No

Employment Status (while attending UPB): ☐ None ☐1-19 hrs/week

☐ 20-39 hrs/week ☐40+ hrs/week

Will you be participating in intercollegiate athletics at Pitt-Bradford? ☐Yes ☐No

If yes, which sport(s)? ___________________________________________________________________

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Current UPB Student

Enrollment Information: Major(s): __________________________________________________

Minor(s) __________________________________________________

Financial Aid: Is your FAFSA submitted? ☐Yes ☐No

Are you eligible/or do you receive Veteran Benefits? ☐Yes ☐No

Enrollment Status: ☐Full time ☐¾ time ☐Part-time ☐Other

(12+credits) (9-11 credits) (6-8 credits)

Academic Level: ☐Freshman—below 23 credits ☐Sophomore—23.5-53 credits

☐Junior—53.5-83 credits ☐Senior—83.5+ credits

Academic Standing ☐Good ☐Academic Probation

Financial Aid Standing ☐Good ☐Financial Aid Probation

Degree Plans at UPB: ☐Bachelor’s ☐Associate

Future Degree Plans (after UPB): ☐Doctorate ☐Master’s ☐Bachelor’s ☐Unsure ☐None

Will You be Transferring from UPB before Graduating? ☐Yes ☐No

Employment Status (while attending UPB): ☐None ☐1-19 hrs/week

☐ 20-39 hrs/week ☐40+ hrs/week

Are you participating in intercollegiate athletics at Pitt-Bradford? Yes☐ ☐No

If yes, which sport(s)? ___________________________________________________________________

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TRIO Student Support Services (SSS) Needs Assessment What would you like to learn more about--CHECK ALL THAT APPLY.

Academic Information Undeclared—Choosing Majors

Academic Advising/

Academic Goal Setting

Time Management

Preparing For and Taking College Exams

Test Anxiety

Organizational Skills

Note Taking Strategies

TRIO SSS Peer Mentor/Success Coach Program

Connecting to Pitt-Bradford’s Tutoring Services

Strategies for Reading College Textbooks

Learning Style Assessment

Project Sponsored Professional Tutors in areas of Remedial Math, Basic Writing Skills, & ESL

Personal Development Financial Literacy/Budgeting

Goal Setting

Leadership Development

Campus Involvement

Volunteering/Community Service

Cultural Enrichment Activities

Social Activities

TRIO SSS Peer Mentor/Success Coach Program

Locating Scholarships

Career Exploration Exploring Career Options

Career Assessments

Resume Creation

Interview Etiquette

Internship Search

Job Search Process

Networking

Graduate/Professional School Exploration Graduate/Professional School Opportunities

Graduate/Professional School Planning

Graduate/Professional School Visits

Graduate/Professional School Entrance Exams

What obstacles do you face or anticipate in college? Choose as many all that apply. Cultural/Language Issues

Out of School for More Than 5 years

Self-confidence

Finding Friends/Community

Access to Technology for School

Financial Issues

Seeking Employment

Transportation Issues

Housing Issues

Attendance

Procrastination

Test Anxiety/Focus & Attention

Navigating Campus Procedures/Services

Undeclared Major/Undecided Career Path

Family Responsibilities

Academic Probation/Academic Standing

Family support/College Knowledge

Personal Identity

Please provide a one to two paragraph response to each of the following two (2) questions

1. Describe how TRIO SSS can help you accomplish your academic goals.

2. Describe your career goal and how the TRIO SSS program can assist you in achieving that goal.

End of Application Thank you